Outcomes in Third and Fourth Kidney Transplants Based on the Type of Donor

[Surgical outcomes and complications following third kidney transplantation]

BACKGROUND

After two consecutive kidney transplant failures, a third kidney transplantation improves survival for patients on the waiting list. The surgical outcomes and complications of third kidney transplantations remain poorly known.

METHODS

We analyzed the last 100 third kidney transplantations performed in our center between January 2000 and August 2018. The data, relating to donors and recipients, were extracted retrospectively from medical records and from the prospective DIVAT database (computerized and validated data in transplantation). Continuous variables are expressed as means, medians, first and third quartiles (median, [Q1;Q3]). Categorical variables are expressed as percentages. Patient and transplant survivals were calculated using the Kaplan-Meier method.

RESULTS

Mean age of recipients was 46.4 years (47, [36;53]). Thirty-five percent had kidney failure due to urinary tract malformations. Mean age of donors was 48.2 years (52, [39.75; 58]) with 63% of donors with standard criteria. Mean cold ischemia time was 22.4hours (21, [16.5; 29.2]). Surgical mortality rate was 2% and surgical complication rate was 45%. Third kidney transplants survival was 73.1% and 58.8% at 5 years and 10 years. Mortality rate with a functioning transplant was 18%.

CONCLUSION

A third kidney transplant offers satisfactory functional outcomes but remains associated with high morbi-mortality and a significant death rate with a functioning transplant.

LEVEL OF EVIDENCE: 4

Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review

BACKGROUND

There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes.

METHODS

We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility.

RESULTS

Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains.

CONCLUSIONS

Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.

Pediatric kidney retransplantation focused on surgical outcomes

INTRODUCTION

Despite survival rates after pediatric kidney transplantation (KT) are on the rise it is still likely that most pediatric recipients will require more than one retransplant in their lifetime. The earlier the age at the first KT the higher is the risk of repeat pediatric kidney transplantation (RPKT).

OBJECTIVE

The current study aims to analyze the outcomes of repeat pediatric kidney transplantation (RPKT) among pediatric kidney transplant recipients focusing on surgical complications and compare the outcomes of second and subsequent grafts with those of the first kidney graft.

MATERIALS AND METHODS

Retrospective study of RPKT (<18 years) undertaken between January 2000-2020. We analyzed primary etiology of renal disease, time to graft loss (GL), etiology of initial graft failure, history of acute rejection, previous delayed graft function, HLA-mismatches at the initial transplant, surgical complications and outcomes. Additionally, we compared the characteristics and outcomes of patients who underwent RPKT (group 1) with those who received a first kidney graft (group 2).

RESULTS

Out of 229 kT, 59 patients underwent RPKT (26 females/33 males). At the time of RPKT median age was 11.37 years (SD:5.7). The most frequent primary renal disease was congenital nephrotic syndrome in 11 (18.6%). Fifty-four (91.5%) were on renal replacement therapy at the time of transplant. Fourty-one patients received their second KT (69.5%), 14 (23.7%) the third, 3 (5.1%) the fourth and 1 (1.7%) the fifth. Transplant graft nephrectomy (GN) was performed in 26 patients (44.1%) prior to retransplantation. Fifty-four (91.5%) received a cadaveric graft and 5 (8.5%) a living-related graft. An extraperitoneal approach was achieved in 53 patients (89.8%), whereas in the remaining 6 (10.2%) the graft was placed intraperitoneally. We observed 10 surgical complications (16.9%): 9 major which required reintervention and 1 minor (perirenal hematoma). No vascular complications were observed and none of the surgical complications were involved in graft loss. Graft survival at 1,3 and 5 years was 91%, 84% and 73% respectively. The most frequent cause of GL was chronic graft nephropathy in 15 (25.4%). After a mean follow-up of 9.40 years (SD: 4.7) only 2 patients died (3.4%), both with functioning grafts.

DISCUSSION

Pediatric recipients of second and subsequent kidney grafts constitute a remarkable high-risk population but are becoming more frequent at reference pediatric transplant centers.

CONCLUSIONS

RPKT is technically challenging but can yield good results. In our series overall the incidence of surgical complications and particularly vascular complications was low.

Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss

An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.

How to Deal With Kidney Retransplantation-Second, Third, Fourth, and Beyond

Kidney transplantation is the best health option for patients with end-stage kidney disease. Ideally, a kidney transplant would last for the lifetime of each recipient. However, depending on the age of the recipient and details of the kidney transplant, there may be a need for a second, third, fourth, or even more kidney transplants. In this overview, the outcome of multiple kidney transplants for an individual is presented. Key issues include surgical approach and immunologic concerns. Included in the surgical approach is an analysis of transplant nephrectomy, with indications, timing, and immunologic impact. Allograft thrombosis, whether related to donor or recipient factors merits investigation to prevent it from happening again. Other posttransplant events such as rejection, viral illness (polyomavirus hominis type I), recurrent disease (focal segmental glomerulosclerosis), and posttransplant lymphoproliferative disease may lead to the need for retransplantation. The pediatric recipient is especially likely to need a subsequent kidney transplant. Finally, noncompliance/nonadherence can affect both adults and children. Innovative approaches may reduce the need for retransplantation in the future.

Comparing outcomes of third and fourth kidney transplantation in older and younger patients

Performing third or fourth kidney transplantation (3KT and 4KT) in older patients is rare due to surgical and immunologic challenges. We aimed to analyze and compare the outcomes of younger (18-64 years) and older (≥65 years) recipients of 3KT and 4KT. Between 1990 and 2016, we identified 5816 recipients of 3KTs (153 were older) and 886 recipients of 4KTs (18 were older). The incidences of delayed graft function (24.3% vs. 24.8%, p = .89), primary non-function (3.2% vs. 1.3%, p = .21), 1-year acute rejection (18.6% vs. 14.8%, p = .24), and 5-year death censored graft failure (DCGF) (24.8% vs. 17.9%, p = .06) were not different between younger and older recipients of 3KT. However, 5-year mortality was higher in older recipients (14.0% vs. 33.8%, p < .001) which remained significant after adjustment (aHR = 3.21, 95% CI: 2.59-3.99). Similar patterns were noted in the 4KT cohort. When compared with waitlisted patients, 3KT and 4KT are associated with a lower risk of mortality; aHR = 0.37, 95% CI: 0.33-0.41 and aHR = 0.31, 95% CI: 0.24-0.41, respectively. This survival benefit did not differ by recipient age (younger vs. older, p for interaction = 3KT: .49 and 4KT: .58). In the largest cohort described to date, we report that there is a survival benefit of 3KT and 4KT even among older patients. Although a highly selected cohort, our results support improving access to 3KT and 4KT.

Repeated kidney re-transplantation in times of organ shortage - a critical review

PURPOSE OF REVIEW

Organ shortage forces those responsible to streamline allocation rules to provide a maximum of candidates with a graft and to optimize transplant outcome. Recently, repeated kidney re-transplantation was investigated in several studies with different analytic settings concerning the control group, the donors, parameters influencing outcome, and demographic characteristics. This review gives an overview on the candidates awaiting a repeated re-transplantation, summarizes the outcome, and comments on the relevance of these findings in the context of sustained organ shortage.

RECENT FINDINGS

Repeated kidney re-transplantation is technically and immunologically feasible and the recipients' survival is better compared to candidates remaining on dialysis or on the waiting-list. However, the outcome is mainly reported to be worse as compared to first or second kidney transplantation. Kidneys from living donors seem to have a favorable impact on outcome in this setting.

SUMMARY

The survival benefit of repeated re-transplantation recipients over patients on dialysis demands for continuation of this procedure. Comprehensive registries are essential to continuously optimize allocation. Governmental authorities are obliged to set the course to increase organ donation rather than forcing transplant decision makers to withhold a third or fourth graft from any candidate.

Analysis of the Peak Systolic Velocity in the Transplant Renal Artery Anastomosis to Determine Normal Values in Patients Without Graft Dysfunction

Objective:

The primary purpose is to define the mean renal artery anastomosis peak systolic velocity (RAA PSV) and the renal artery anastomosis to external iliac artery ratio (RAA-to-EIA) of renal transplant recipients without graft dysfunction. Moreover, to determine associations with type of vascular anastomosis and type of graft.

Materials and Methods:

This is a single-center retrospective analysis of kidney transplant recipients. Recorded variables included recipient age, type of vascular anastomosis, type of graft, RAA PSV, and external iliac artery PSV (EIA PSV). Such variables were evaluated on different postoperative follow-up periods.

Results:

There was a high degree of reliability between the RAA PSV and EIA PSV ( P < .001). The mean RAA PSV was 174 cm/s ± 72.9 cm/s with 95% confidence interval (CI) (162.2 cm/s-185.5 cm/s].

Conclusion:

This study highlights the importance of determining the normal range of RAA PSV and showed that a high PSV does not necessarily indicate dysfunction.

Outcomes of first versus third kidney transplantations: propensity score matching and paired subgroup analysis-a single-centre experience

Background

In the Eurotransplant, 12.6% of kidney transplantations are a repeat procedure. Third transplants are significantly more complex than first and second ones. We compared the results of first (PRT) versus third (TRT) transplantations.

Methods

Between 2011 and 2016, we performed 779 deceased donor adult kidney transplantations, 14.2% out of them were second, 2.6% (20) third, and 0.3% fourth. We compared the pre-, intra-, and postoperative data, kidney function, and survival rate.

Results

Recipients of TRT were younger (53.4 vs. 47.3 p = 0.02). HCV infection rate (20%, p = 0.00) is ten times higher. The operation time is longer (132 vs. 152 min, p = 0.02), and delayed graft function is much more frequent (22.4% vs. 60%, p = 0.00). Induction therapy was given to every TRT (7.9% vs.100%), but as a result, the rejection rate was the same (~ 15%). Hospital stay is a week longer. Patient’s survival at 1, 3, and 5 years for PRT is 96.4%, 93.9%, and 91.2% and for TRT is 90%, 85%, and 78.4%, respectively (p = 0.023). TRT’s odds ratio of fatal outcome is 4.35 (1.5–12.5). Graft survival at 1, 3, and 5 years for PRT is 93.1%, 91.4%, and 90.3% and for TRT is 75%, 75%, and 75%, respectively (p = 0.020). TRT’s odds ratio of graft loss is 3.14 (1.1–8.9). Of PRT 85.76%, out of PRT 85.76%, while out of TRT 60% live with a functioning graft, p=0.00149.

Conclusion

In a third transplant, both graft and patient survival are significantly inferior to primer ones. Careful selection is required to minimize the patient risk and graft loss.

Living Donor Kidney Transplantation Improves Graft and Recipient Survival in Patients with Multiple Kidney Transplants

BACKGROUND

Failed kidney transplant recipients benefit from a new graft as the general incident dialysis population, although additional challenges in the management of these patients are often limiting the long-term outcomes. Previously failed grafts, a long history of comorbidities, side effects of long-term immunosuppression and previous surgical interventions are common characteristics in the repeated kidney transplantation population, leading to significant complex immunological and technical aspects and often compromising the short- and long-term results. Although recipients' factors are acknowledged to represent one of the main determinants for graft and patient survival, there is increasing interest in expanding the donor's pool safely, particularly for high-risk candidates. The role of living kidney donation in this peculiar context of repeated kidney transplantation has not been assessed thoroughly. The aim of the present study is to analyse the effects of a high-quality graft, such as the one retrieved from living kidney donors, in the repeated kidney transplant population context.

METHODS

Retrospective analysis of the outcomes of the repeated kidney transplant population at our institution from 1968 to 2019. Data were extracted from a prospectively maintained database and stratified according to the number of transplants: 1st, 2nd or 3rd+. The main outcomes were graft and patient survivals, recorded from time of transplant to graft failure (return to dialysis) and censored at patient death with a functioning graft. Duration of renal replacement therapy was expressed as cumulative time per month. A multivariate analysis considering death-censored graft survival, decade of transplantation, recipient age, donor age, living donor, transplant number, ischaemic time, time on renal replacement therapy prior to transplant and HLA mismatch at HLA-A, -B and -DR was conducted. In the multivariate analysis of recipient survival, diabetic nephropathy as primary renal disease was also included.

RESULTS

A total of 2395 kidney transplant recipients were analysed: 2062 (83.8%) with the 1st kidney transplant, 279 (11.3%) with the 2nd graft, 46 (2.2%) with the 3rd+. Mean age of 1st kidney transplant recipients was 43.6 ± 16.3 years, versus 39.9 ± 14.4 for 2nd and 41.4 ± 11.5 for 3rd+ (p < 0.001). Aside from being younger, repeated kidney transplant patients were also more often males (p = 0.006), with a longer time spent on renal replacement therapy (p < 0.0001) and a higher degree of sensitisation, expressed as calculated reaction frequency (p < 0.001). There was also an association between multiple kidney transplants and better HLA match at transplantation (p < 0.0001). A difference in death-censored graft survival by number of transplants was seen, with a median graft survival of 328 months for recipients of the 1st transplant, 209 months for the 2nd and 150 months for the 3rd+ (p = 0.038). The same difference was seen in deceased donor kidneys (p = 0.048), but not in grafts from living donors (p = 0.2). Patient survival was comparable between the three groups (p = 0.59).

CONCLUSIONS

In the attempt to expand the organ donor pool, particular attention should be reserved to high complex recipients, such as the repeated kidney transplant population. In this peculiar context, the quality of the donor has been shown to represent a main determinant for graft survival-in fact, kidney retrieved from living donors provide comparable outcomes to those from single-graft recipients.

Beyond the Limits: How to Avoid a Surgical Nightmare in the Third and Subsequent Renal Transplantation Procedures

PURPOSE OF REVIEW

Approximately, 25% of the patients with ESRD will enter the waiting list for kidney transplantation. Among these patients, almost 15% will require a retransplantation surgery. This review aims to summarize the most recent information on different controversial issues regarding retransplantation, to provide the reader with a clear and updated view on the topic.

RECENT FINDINGS

Despite current evidence is mainly based on retrospective, small, single-center experiences, it seems clear that retransplantation remains a surgical and immunological challenge, for which the perioperative management still remains crucial to avoid mishaps. Different surgical approaches have been tested, but the general consensus advocates for the heterotopic extraperitoneal in first instance. Although higher immunological risk and complication rates are reported invariably in the available series, the benefits in terms of overall survival are superior to those obtained under dialysis, thus still representing the most recommended option for this group of patients.

Double Obstruction Following Third Renal Transplant: A Case Report

As the field of transplant evolves and patients with chronic disease live longer, retransplant for end-stage renal disease becomes more common because kidney allografts have a limited lifespan. In renal retransplant, graft and patient survival is near equivalent to first-time transplant; however, these procedures present a unique surgical risk profile, especially third and subsequent transplants, which are reviewed in this manuscript. The risk of bowel obstruction in primary kidney transplant recipients is much lower than patients who have undergone laparotomy for second or third transplant because of the retroperitoneal location of the transplanted kidney. Internal hernia is an uncommon cause of small bowel obstruction, particularly after kidney transplant, and often diagnosis and intervention are delayed because of diagnostic uncertainty. We report a case of a 34-year-old man with acute kidney injury and bowel obstruction, whose final diagnosis was an internal hernia around the transplanted ureter of an intra-abdominally placed third renal transplant resulting in ureteric obstruction associated with small bowel obstruction-a case of double obstruction.